Management Of Vascular Malformations Research Articles

Surgical Management of Vascular Malformations of the Upper Extremity: A 12-Year Retrospective Cohort Study.

Vascular malformations (VMs) typically appear at birth and grow commensurately with patients. They can vary broadly in vessel type and tissue involvement, and upper extremity (UE) VMs can pose unique functional and aesthetic challenges in children. Given the advent of operative and nonoperative technologies like sclerotherapy and medications, a contemporary review of the surgical management of UE VMs is warranted. We performed a retrospective review of all patients who had surgical management of VMs from 2010 to 2021 at The Children's Hospital of Philadelphia. Demographics, lesion characteristics, treatment (including preceding nonsurgical therapies), complications, and final outcomes were recorded. Operative notes were reviewed for date of operation, depth of excision, type of closure, and current procedural terminology code. Sixty-seven patients with 88 procedures were studied. Average patient age was 5.8 years, with 64% White and 67% male. Venous (34%) and lymphatic (19%) malformations were most common, and anatomic locations were most frequently on the hand (33%) and forearm (25%). The average lesion diameter was 4.2 cm, although this varied by location (eg, 2.9 cm, hand; 11.1 cm, chest wall). Fifty-eight patients (87%) underwent surgical excision as their index procedure, and 9 had sclerotherapy before surgery. Thirty-nine patients (60%) had subcutaneous excisions, and the remainder required subfascial or intramuscular excisions. Nearly all excisions were closed primarily (97%). Of the 53 patients with documented follow-up, 32 patients (60%) had complete resolution of their lesion as of their final visit. Thirty of these 32 patients with no clinical evidence of residual VM had only 1 surgery for excision. Upper extremity VMs were composed of diverse conditions with varying vessel types, size, depth, and anatomic sites. Surgical excision of VMs of the UE was safe and effective. A majority of VMs were fully excised after 1 procedure and frequently closed primarily with relatively low complication rates. Future work should investigate decision-making and outcomes of all treatment options of VMs of the UE for optimal functionality and aesthetics.

Management of Vascular Malformations in the Oral Cavity: Case Report

Vascular anomalies are diverse, and several classifications are available for these anomalies, the most recent and accepted classification is that of the "International Society for the Study of Vascular Anomalies (ISSVA) that was made in 2014 and revised in 2018. It divides vascular anomalies into vascular tumors (including hemangiomas) and vascular malformations. Various treatment modalities are available, including laser therapy, steroid therapy, embolization, blocking therapy, sclerosing therapy, surgery or cryosurgery. This article presents the usefulness of CO2 laser and diode laser for the treatment of vascular anomalies of the oral cavity, while presenting an unusual combination, for the treatment of an oral hemangioma associated with an angiomatous epulis, between sclerotherapy and diode laser. This study not only confirmed the treatment's effectiveness in reducing lesion size and minimizing intraoperative bleeding from the epulis but also highlighted its ability to enhance aesthetic outcomes, patient comfort, and overall satisfaction.

Real-World Data on the Use of Sirolimus in Asian Children with Vascular Malformations.

The management of vascular malformations is complex and challenging. This study aimed to explore efficacy, plasma trough concentrations of sirolimus, post-withdrawal conditions, and adverse reactions of sirolimus in treating complex vascular malformations. In our center, we analyzed vascular malformations treated with sirolimus (and corticosteroid) from August 2017 to June 2021. Meanwhile, we reviewed the medical records, the efficacy, side effects, and laboratory tests. Patients who had stopped taking sirolimus were followed up by telephone. A total of 25 patients with complicated vascular malformations in our center, including 7 females and 18 males aged 4 months to 15 years, were enrolled. In all, 19 patients (76.0%) responded to sirolimus, and the plasma concentration of sirolimus fluctuated between 0.97 and 27.15ng/ml. In all, 24 patients (96.0%) were in follow-up. A total of 15 patients (62.5%) stopped taking sirolimus during follow-up, and 2 patients (13.3%) discontinued the sirolimus due to side effects. A total of 3 patients (20.0%) restarted sirolimus treatment. Starting dose of 1.5-2 mg/m2 sirolimus is effective and safe in vascular malformation treatment. The best treatment regimen and discontinuation indications needed more investigation. Most should be done about targeted therapy to improve effectiveness and reduce side effects.

Cerebral Arteriovenous Malformation, Cerebral Cavernoma, and Cerebral Aneurysm: Management and Outcome During Pregnancy and Puerperium with Focus on Neurosurgical Side

Background: Cerebral cavernoma, cerebral arteriovenous malformation, and incidental cerebral aneurysm are rare but challenging conditions during pregnancy and puerperium. The primary diagnostic and identification techniques used to determine and evaluate these conditions in terms of morphology, location, and presentation are brain CT scan, MRI, and DSA. With ideal treatment of these conditions still unclear, neurosurgery is the most commonly preferred intervention technique. Objective: The aim of extracting data from the published studies to identify the most common neurosurgical procedures used for successful management and outcomes of CCM, cerebral AVM, and incidental cerebral aneurysms during pregnancy and puerperium. Methods: It was performed as comprehensive search into PubMed, Google Scholar, Science Direct, PubMed Central, Medline, and Research Gate databases for studies published between January 2000 to 20th January 2022. The search terms were "Cerebral cavernoma" or "cavernous cerebral malformation" or "CCM" or "cavernoma in pregnancy and puerperium"; "cerebral arteriovenous malformations" or "arteriovenous malformations" or "AVM"; "cerebral incidental aneurysm" or "intracranial aneurysm" or "incidental aneurysm" or "cerebral aneurysm in pregnancy"; "intracranial vascular malformations"; "neurosurgical treatments in pregnancy and puerperium"; "management of vascular malformation." Results: A total of 11 studies met our inclusion criteria and were included for the review. From the studies reviewed, the significant neurosurgical intervention performed among the participants were craniotomy, surgical resection, endovascular techniques, surgical clipping, surgical evacuation, embolization, and dissection. Conclusion: It concluded that effective management and treatment must be done independently and specific to each case presented. The multidisciplinary treatment option is fundamental for successful management outcomes during pregnancy and puerperium.

Pathological Spectrum of Vascular Malformations of the Central Nervous System: A Single Institution Experience of a Decade

Abstract Background Vascular malformations (VMs) of the central nervous system comprise a variety of lesions that could affect the arteries, veins, or capillaries. Materials and Methods We analyzed the histopathological features of all the VMs diagnosed at our centre over a decade. Results Intracranial VM included arteriovenous malformation (AVM) (53%), cerebral cavernous malformations (CCMs) (45%), capillary telangiectasia (2%), venous angioma (0.5%), and arteriovenous fistula (AVF) (0.5%). In spinal VMs, capillary telangiectasia (40%) were the most common, followed by cavernomas (34%), AVF (16%), and AVMs and venous angiomas (5%). Clinical presentation varied from focal deficit to features of raised intracranial tension. Conclusion Imaging and histopathology plays an important role in the diagnosis and management of VMs. Histopathological examination is essential for characterization of the VMs, which influences the prognosis.

Pharmacokinetics of bleomycin sclerotherapy in patients with vascular malformations.

Bleomycin, a chemotherapy agent that inhibits synthesis of DNA, has been increasingly utilized in sclerotherapy for patients with vascular malformations. A serious long-term risk of intravenous bleomycin is dose-dependent interstitial pneumonitis. Little is known about absorption and circulating levels of bleomycin when used in sclerotherapy for patients with vascular malformations. This is an Institutional Review Board (IRB)-approved prospective study on patients receiving bleomycin sclerotherapy in the management of vascular malformations. Depending on the type of vascular malformation, bleomycin was administered either in the lumen or interstitial space of the involved lesion. A bleomycin assay measured serum bleomycin plasma concentrations versus time at seven intervals following treatment. Pharmacokinetic parameters were obtained for each participant and included peak plasma concentration (Cmax ), time to reach peak plasma concentration (Tmax ), volume of distribution (Vd ), elimination half-life (t1/2 ), the volume of plasma cleared of the drug per unit time (CL), and total systemic exposure area under the curve (AUC). Fifteen patients were enrolled (5: lymphatic, 4: venous, 6: arteriovenous malformations). Bleomycin was administered interstitially (IS) in 11 patients and intraluminal (IL) in four; median age of 13years (range: 2-67). Pharmacokinetic analysis revealed terminal elimination half-life (t1/2λz ) of 88.51 (±23.09) and 111.61 (±37.75) minutes for the IS and IL groups, respectively. Vd was 4.86L (±6.74) and 1.55L (±0.54) for the IS and IL groups, respectively. AUC was 53.9 (±23.45) and 129.17 (±93.57) mgmin/L for the IS and IL groups, respectively. There were no statistically significant differences in t1/2λz , Vd , or AUC parameters between groups. Bleomycin is absorbed systemically when used as a sclerosant for vascular malformations when injected either IS or IL.

Bleomycin Electrosclerotherapy Treatment in the Management of Vascular Malformations.

Intralesional injection of a sclerosing agent is a standard treatment for vascular malformations, but many repeat treatments are often required to achieve a response. The temporary application of an electrical field to the treated area increases cellular membrane permeability and therefore augments drug delivery. To report a case series of patients with vascular malformations who received bleomycin electrosclerotherapy (EST). A prospective observational case series of patients with vascular malformations treated with bleomycin EST. Only patients who did not respond or had limited response to standard sclerotherapy were included. The response to the treatment was assessed using a global assessment score and patient-reported outcome measures. Thirty patients were treated with EST. Most of the patients had venous malformations (57%). Complete response or significant improvement was observed in 17 (57%) and 7 (23%) patients, respectively. Most of the patients were satisfied or very much satisfied with the outcome of the treatment. Most commonly reported complications were swelling, pain, and bleeding. Electrosclerotherapy is a promising method of augmenting the efficacy of intralesional bleomycin injections when treating vascular malformations. It can potentially lead to a reduction in the administered dose and number of treatment sessions needed.

The Addition of Lipid-Based Contrast Medium does not Inactivate the Detergent Sclerosant Sodium TetradecylSulfate in-vitro.

To investigate if the detergent sclerosant sodium tetradecyl sulfate (STS) is deactivated by the lipid-based contrast agent ethiodised oil. 3% STS was mixed with ethiodised oil and room air in a 2:1:4 ratio in two luer lock syringes and a three way connector and agitated to make foam (the Tessari technique) to replicate the clinical use of the products. The assay of STS in the mixture was assessed using the British Pharmacopoeia method. Briefly this is a manual titration method where the solution of STS is mixed with an indicator solution and titrated with hyamine solution of known concentration; the concentration of the STS can then be calculated with the titration results. To further mimic the clinical environment with the presence of blood, the effect of adding increasing amounts of albumin to the STS-ethiodised oil mixture was assessed. The assay of STS in the solution after mixing with ethiodised oil was 3% indicating that the ethiodised oil did not deactivate the STS. The addition of albumin to the STS-contrast mixture resulted in near linear neutralisation of the STS with increasing concentrations in the same quantities as with STS alone. The mixture of the lipid-based contrast agent ethiodised oil with the detergent sclerosant STS did not affect the availability of the sclerosant. The continued use of STS-ethiodised oil in the management of vascular malformations can be supported.

Management of vascular malformations in the Oral and maxillofacial region: A systematic review

ObjectiveThe purpose is to determine the comprehensive review and the current concepts on the management of vascular malformation and to evaluate the long term outcomes, recurrence and complication rate. MethodsThis systematic review followed PRISMA guidelines and registered in PROSPERO (CRD42020173735). The PUBMED, EBSCO, SCOPUS and NDH databases were used to perform a comprehensive search of articles published up until July 2020. The database search identified 1719 articles. After an intricate review, 34 studies were estimated for eligibility. ResultsA total of 1719 patients with mean age of 27.48 years were treated for vascular malformation in the oral and maxillofacial region. Moderate heterogeneity was observed for the outcome (P = 0.166; 95% CI:1.01–1.46, I2 = 48%). As determined by one-way ANOVA, there was no statistically significant difference between the type of diagnosis and the recurrence (F = 2.313, p = 0.092) and the complication rate (F = 2.112, p = 0.117). ConclusionIn accordance with the available scientific literature, this review has highlighted the modalities and advancement in the management of vascular malformations. Complications and recurrence were reported in all types of management. It can be avoided by careful diagnosis, pre-operative assessment and treatment planning.

Efficacy and safety of sirolimus in the treatment of vascular malformations: A protocol for systematic review and meta-analysis.

Background:The pathophysiologic of vascular malformations is still unclear, and the treatment of vascular malformations is a challenge. With improvement in the understanding of pathogenesis of vascular malformations, sirolimus has been a promising and effective treatment. As so far, there is absent convincing evidence to confirm the efficacy of sirolimus for vascular malformations. The purpose of this study was to evaluate the effectiveness and safety of sirolimus in the treatment of vascular malformations.Methods:The literatures about the management of vascular malformations with sirolimus would be searched from databases of MEDLINE, EMBASE, PubMed, Web of Science, Clinicaltrials.org., Cochrane Library, China Biology Medicine Database (CBM), Wan Fang Database, China National Knowledge Infrastructure Database (CNKI), and VIP Science Technology Periodical Database. We will search each database from inception or 1995 to August 20, 2020. Two researchers worked independently on literature selection, data extraction and quality assessment. The efficacy and safety of sirolimus in the treatment of vascular malformations were the main outcomes. Adverse events after sirolimus were evaluated as the secondary outcomes. The included studies will be analyzed by Review Manager 5.3. If the results are applicable, meta-analysis would also be performed.Results:The study will evaluate the efficacy and safety of sirolimus in the treatment of vascular malformations based on current evidence.Conclusion:The conclusion of this study will provide more reliable, evidence-based data for the use of sirolimus in the treatment of vascular malformations.PROSPERO registration number:CRD42020167881.

Updated classification and therapy of vascular malformations in pediatric patients.

Vascular malformations (VMs) comprise a diverse group of diagnoses. They are classified by the type of vessel involved, including capillaries, veins, arteries, lymphatic vessels, or combinations of these. Complex VMs, although benign, can impair vital structures, cause deformations, or even threaten the child's life. Although multimodal treatment of VMs in children with disease include a wide variety of options such as observation, laser therapy, sclerotherapy, surgical resection, radiofrequency ablation, and medical therapy, the management of VMs necessitates a multifocal and multidisciplinary method with the patient's quality of life as the priority.

Combined Surgery and Intraoperative Sclerotherapy for Vascular Malformations of the Head/Neck

Vascular malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result, resections of large VMs are often performed in a multistage approach. This article introduces a new hybrid approach for the management of head and neck VMs entailing the use of an endovascular operating room where a neuroendovascular surgeon performs embolization or sclerotherapy intraoperatively as needed in conjunction with surgical excision. Three patients with large VMs in the facial region underwent successful use of the hybrid approach. The hybrid approach improved visualization, leading to complete resection in 1 patient and nearly complete resections (70% and 90%) in the other patients. The technique also helped minimize blood loss because only the youngest patient (23 months old) required a blood transfusion. Implications of these findings include the transition from a multistaged approach for large VMs to a single-stage approach. In addition, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

Outcome Measures After Sclerotherapy of Venous Malformations: A Systematic Review.

Sclerotherapy has become an important treatment option in the management of vascular malformations. However, little is known about success rate for treatment of venous malformations. This systematic review assesses the available published literature on outcome measures of sclerotherapy for venous malformations. PubMed and EMBASE. A systematic search was conducted, and studies from March 2008 to October 2016 were included. Based on the identified search results, study selection, data extraction, and assessment of study quality were, according to PRISMA, undertaken independently by two reviewers. One randomized controlled trial and 44 cohort studies were included. The most frequently used measuring methods were subjective measurements, objective measurements, imaging like MRI and ultrasound, and finally patient reported outcome measure survey. Approximately 60% of the studies used more than one measuring method. Outcome measures were pain, swelling, disfigurement, cosmetic complains, patient satisfaction, physical difficulties, volume, diameter, mass, color, shape, size, venous flow, occlusion of venous space, blood pool ratio, and radioisotope uptake. The published literature over the past 10years shows no clear method to evaluate the effect of sclerotherapy for venous malformation. We suggest that a standard set of outcome measures should be defined.

Harmonic devices: The workhorse for surgical resection of vascular malformations

Management of vascular malformations is multimodal with documented role of surgical resection in specific facets of this condition. Surgical resection of these lesions is technically challenging owing to diffuse and relatively ill-defined extent with involvement of multiple tissue planes limitation of access and excessive intra-operative bleeding. An observational study was conducted in 24 cases taken up for surgical resection of vascular malformations. The cases were divided into two groups based on the hemostasis technique used: Group A: Harmonic shears (n = 12) (Ethicon Inc. Somerville, New Jersey, United States). Group B: Electrosurgery (monopolar/bipolar) with standard knot tying (n = 12). We conclude that use of harmonic scalpel in surgical resection causes less parallel tissue damage, secures haemostasis promptly, does not impede vision and aids surgical dissection thereby significantly reducing the operative time and improving the surgical outcome, typically in large vascular malformations of head and neck region.

Vascular medicine and foam sclerotherapy for venous malformations

Vascular medicine plays a determining role in the management of vascular malformation, especially venous malformations. Ideally, therapeutic decision should be made in a multidisciplinary staff meeting. Vascular medicine plays the leading role for diagnosis and duplex-Doppler evaluation of coagulation disorders, potentially associated with an assessment of treatment feasibility using chemical or thermic endovascular techniques. Potential adherence of compression therapy must also be evaluated. Decision trees often mention sclerotherapy for the management of venous malformations. Echo-guided foam sclerotherapy is preferred. The superiority of foam sclerotherapy over liquid sclerotherapy has been demonstrated. Indications and limitations of this specific treatment remain to be definitively determined, especially for treatments with radiological control. Side effects are now well described for the use of foam sclerotherapy for venous malformations. They remain limited. Future developments should help optimize the sclerosing effect of currently used foams or other products to be developed. For the vascular medicine specialist, the main contribution is to define the appropriate use of echo-guided sclerotherapy.

Management of vascular malformations on the tongue by hot saline injection: a case report

Management of vascular malformations on the tongue by hot saline injection: a case report

Malformations veineuses superficielles cervico-faciales. Mise au point

Management of vascular malformations and vascular tumors has recently been maximized by the establishment of an accurate clinical and histological classification and by the development of multidisciplinary expert consultations. Head and neck localizations of venous malformations are common, thus maxillo-facial surgeons should be aware of the characteristics of this pathology and the principles of its management. Diagnosis is mainly clinical and must be certified by Doppler-ultrasonography and contrast enhanced magnetic resonance imaging with T2 fat-saturation sequence. Therapeutic decision depends on the volume of the lesion, and on functional, cosmetic and psychological complaints. Sclerotherapy is now the preferred treatment of head and neck venous malformations. It is performed in specialized interventional radiology units by intralesional injections of sclerosing solution under fluoroscopic guidance. Surgery is useful in some cases, either on its own or following sclerotherapy. In case of bulky lesion, it is necessary to search for and prevent a severe coagulopathy before planning any intervention.

A novel technique for the management of vascular malformations of the face

A novel technique for the management of vascular malformations of the face

Management of vascular malformations.

Background:Even though vascular malformations are well categorized, further details are relatively unknown. Of treated patients regarding the frequency, demographic distributions, and other related factors by multivariate regression analyses in proportion to total vascular malformations, methods of treatment and how to manage them have not been elucidated thoroughly.Methods:From January 2006 to March 2012, consecutively treated patients with vascular anomalies were included in this investigation at least 1-year follow-up.Results:Of the total of 123 cases, 86 females and 37 males, the mean follow-up was 3.5 ± 1.68 years, and the frequency of treatment was 1–8 times (1.8 ± 1.30). Surgery was performed for 22 cases (17.9%) of venous malformations and arteriovenous malformations. In multivariate regression, the frequency of treatment was significantly correlated with the length of follow-up (P < 0.001), age (P < 0.05), and type of malformations (P < 0.05) (R2 = 0.18). Need for surgery was significantly increased with age at odds ratio (OR) of 1.06 [95% confidence interval (CI), 1.03–1.80] (P < 0.001), and head/face/neck, and upper limb are more performed at OR of 0.24 (95% CI, 0.07–0.85) (P < 0.05). The satisfaction score varied from 1 to 5 (3.9 ± 0.68). Complications occurred in 3 cases (2.4%). In logistic regression of complications, the OR of the satisfaction score was 0.13 (95% CI, 0.02–0.80) (P < 0.05).Conclusions:Treatment of vascular malformations is an integral part of multidisciplinary approaches. Venous malformations are more frequent in combination surgery, and if there are fewer complications, the patients’ satisfaction increases.

Management of Vascular Malformations in Dangerous Area of Oral Cavity: The Iranian Experience and Review of Treatment Modalities

Aim: To evaluate the effect of a highly potent corticosteroid (dexamethasone) in the treatment of vascular malformation when the location is difficult to reach and complications such as uncontrolled bleeding is predictable in surgery. Background: Vascular malformation is not a common lesion in oral cavity especially in alveolar ridge with extension to the pillar uvula. These lesions arise from capillary or venous malformations with various surgical or non-surgical treatment modalities. Case Description: We performed weekly intralesional injection of dexamethasone in a patient with a vascular malformation in alveolar ridge extending to the lingual side of alveolar ridge and posterior extension to the uvula. Complete resolution of lesion was observed after 6th injection. Conclusion: Intralesional injection of dexamethasone is a potentially curative method to treat oral vascular malformation. Clinical Significance: Injection of dexamethasone is a simple and cost-effective therapy that can be used as a safe treatment for vascular malformations prior to or as a substitute for surgery.